Anderson Adult Education Center
Referral 18-21 Year Old
All applicants 18-21 year olds must submit this form and all required documents listed below before
admission into the Anderson Adult Education GED or High School Diploma classes.
Name________________________________________ SS# _________________________
Address ______________________________________City Zip
Phone Number Date of Birth _______________________ Age
Last School Attended _____________________________________________________________
Address of School if outside of Anderson County
* Student's signature__________________________________________ Date
Reason for leaving school:
(Check all that apply)
Missed too many days resulting in a failing for the year.
Too old for grade placement.
Has already withdrawn/dropped out of school.
Other (Please explain) _____________________________________________________________
Section 2 : High School P r i n c i p a l or Guidance Counselor
Please complete this section if applicant is cleared of all debts owed to your school.
Did this student have? IEP _____________ 504 Plan ______________
Has this student passed HSAP? MATH Yes _____ No________ Date and Score____________
ELA Yes _____ No________ Date and Score____________
Please attach the following documents for this application to the Adult Education Center.
1. Copy of official transcript with HSAP test sc ores
2. Copy of Psychological file (if applicable)
Signature _____Position _____Date_____________
This section is to be completed by Anderson School District Five school administrators.
Fees collected by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ on ______________________
Adult Education Staff Date
□ I recommend this student. □ I do not recommend this student.
Director of Anderson Adult Education Date